* A
benefit period begins on the first day you receive service as an inpatient in a
hospital and ends after you have been out of the hospital and have not received
skilled care in any other facility for 60 days in a row.

** This high deductible plan pays the same or offers the same benefits as Plan
J after you have paid a calendar year $2000 deductible. Benefits from the
high deductible Plan J will not begin until out-of-pocket expenses are
$2000. Out-of-pocket expenses for this deductible are expenses that would
ordinarily be paid by the policy. This includes the Medicare deductibles
for Part A and Part B, but does not include the plan's separate foreign travel
emergency and prescription drug deductibles.

Service:

HOSPITALIZATION*
Semiprivate room and board, general nursing and miscellaneous services and
supplies:

MEDICARE
PAYS

PLAN
PAYS

YOU
PAY

First 60 days

All but $1,100

$1,100 (Part A
Deductible)

$0

61st through 90th day

All but $275 a day

$275 a day

$0

91st day and after:

While using 60 lifetime reserve
days

All but $550 a day

$550 a day

$0

Once lifetime reserve days are
used:

Additional 365 days

$0

100% of Medicare
Eligible Expenses

$0**

Beyond the Additional 365 days

$0

$0

All costs

Service:

SKILLED NURSING FACILITY CARE *
You must meet Medicare's requirements, including having been in a hospital for
at least 3 days and entered a Medicare-approved facility within 30 days after
leaving the hospital:

First 20 days

All approved
amounts

$0

$0

21st through 100th
day

All but $137.50 a day

Up to $137.50 a day

$0

101st day and after

$0

$0

All costs

Service:

BLOOD

First 3 pints

$0

3 pints

$0

Additional amounts

100%

$0

$0

Service:

HOSPICE CARE
Available as long as your doctor certifies you are terminally ill and you elect
to receive these services.

All but very
limited coinsurance for outpatient drugs and inpatient respite care

$0

Balance

**NOTICE: When your
Medicare Part A hospital benefits are exhausted, the insurer stands in the
place of Medicare and will pay whatever amount Medicare would have paid for up
to an additional 365 days as provided in the policy's "Core Benefits." During
this time the hospital is prohibited from billing you for the balance based on
any difference between its billed charges and the amount Medicare would have
paid.

* Once
you have been billed $155 of Medicare-Approved amounts for covered services
(which are noted with an asterisk), your Medicare Part B Deductible will have
been met for the calendar year.

** This high deductible plan pays the same or offers the same benefits as Plan
J after you have paid a calendar year $2000 deductible. Benefits from the
high deductible Plan J will not begin until out-of-pocket expenses are $2000.
Out-of-pocket expenses for this deductible are expenses that would
ordinarily be paid by the policy. This includes the Medicare deductibles
for Part A and Part B, but does not include the plan's separate foreign travel
emergency and prescription drug deductibles.

Service:

MEDICAL EXPENSES - In or Out of the
Hospital and Outpatient Hospital Treatment,
such as Physician's services, inpatient and outpatient medical and surgical
services and supplies, physical and speech therapy, diagnostic tests, durable
medical equipment:

MEDICARE
PAYS

PLAN
PAYS

YOU
PAY

First $155 of Medicare Approved
Amounts*

$0

$155 (Part B
Deductible)

$0

Remainder of Medicare Approved
Amounts

Generally 80%

Generally 20%

$0

Part B Excess Charges (Above
Medicare Approved Amounts)

$0

100%

$0

Service:

BLOOD

First 3 pints

$0

All costs

$0

Next $155 of Medicare Approved
Amounts*

$0

$155 (Part B
Deductible)

$0

Remainder of Medicare Approved
Amounts

80%

20%

$0

Service:

CLINICAL LABORATORY SERVICES

Tests for Diagnostic Services

100%

$0

$0

PARTS
A & B

Service:

HOME HEALTH CARE
Medicare Approved Services:

MEDICARE
PAYS

PLAN
PAYS

YOU
PAY

Medically necessary skilled care
services and medical supplies

100%

$0

$0

Durable medical equipment:

First $155 of Medicare Approved
Amounts*

$0

$155 (Part B
Deductible)

$0

Remainder of Medicare Approved
Amounts

80%

20%

$0

Service:

AT HOME RECOVERY SERVICES - Not
Covered by MedicareHome care certified by your doctor, for personal care during recovery from
an injury or sickness for which Medicare approved a Home Care Treatment Plan:

Benefit for each
visit

$0

Actual charges up to $40 per visit

Balance

Number of visits
covered (must be received within 8 weeks of last Medicare approved visit)

0

Up to the number
of Medicare approved visits, not to exceed 7 each week

Balance

Calendar year maximum

$0

$1,600

Balance

OTHER BENEFITS - NOT COVERED BY MEDICARE

Service:

FOREIGN TRAVEL NOT COVERED BY MEDICARE
Medically necessary emergency care services beginning during the first 60 days
of each trip outside the USA:

First $250 each
calendar year

$0

$0

$250

Remainder of charges

$0

80% to a
lifetime maximum benefit of $50,000

20% and amounts
over the $50,000 lifetime maximum

Service:

***PREVENTIVE MEDICAL CARE
-NOT COVERED BY MEDICARE
Some annual physical and preventive tests and services administered as ordered
by your doctor when not covered by Medicare.

First $120 each calendar year

$0

$120

$0

Additional charges

$0

$0

All costs

***Medicare benefits are subject to change. Please consult the latest Guide
to Health Insurance for People with Medicare and the latest Medicare Handbook.